New Riverdale Rehab: Medication Monitoring Failure - NY
The resident, identified in inspection records only as Resident 39, was prescribed Depakote, a drug that requires periodic monitoring of levels in the blood. Too little and it may not control seizures or mood episodes. Too much and it can damage the liver or cause toxicity. A consulting pharmacist had flagged the need for a serum valproate level, and on February 12, 2025, the facility's nurse practitioner ordered the test. The physician order was documented. The draw was scheduled for the following day.
It was never done.
When inspectors from the New York State Department of Health arrived on March 19, 2025, there was no record that the blood had ever been collected. The test ordered February 12 had simply not happened, and more than five weeks had passed.
The nurse practitioner, interviewed at 9:23 that morning, confirmed the order had been placed in response to the pharmacist's recommendation. Then came the explanation: they wait for the registered nurse to tell them when lab results come back. No one had. The nurse practitioner said they were never notified the sample hadn't been collected, and never told why.
The director of nursing, interviewed about an hour and a half later, offered a different version of where responsibility should have landed. If the sample wasn't collected, the director said, the laboratory should have communicated with the nurse. Then came an acknowledgment that carried its own weight: a follow-up should have been done for laboratory requests that were not completed.
Should have been. Wasn't.
What the inspection report describes is a system in which a medication monitoring order passed through the facility and disappeared. The pharmacist recommended it. The nurse practitioner ordered it. The order was written down. And then nothing happened for five weeks, with each person in the chain assuming someone else was watching.
The consulting pharmacist's original recommendation had been documented. The facility's own response to that recommendation, also documented, read: "Agree. Will do." Nobody did.
The deficiency was cited under New York State regulation 10 NYCRR 415.18(c)(2), which governs pharmaceutical services in nursing facilities. Inspectors classified the level of harm as minimal harm or potential for actual harm, and noted the violation affected a small number of residents.
That classification, minimal harm, reflects what inspectors could document at the time of the survey. What it does not capture is what the five-week gap in monitoring meant for Resident 39's treatment, or whether the Depakote level, had it been drawn, would have shown anything requiring a dosage adjustment.
Depakote is not a drug where monitoring is optional paperwork. The test exists because the margin between a therapeutic dose and a harmful one is narrow, and because the drug's concentration in the blood can shift based on other medications, diet, and the natural changes that come with aging. A consulting pharmacist flagged the need. A physician agreed. A nurse practitioner placed the order.
The blood was never drawn.
New Riverdale Rehab and Nursing is located at 641 West 230th Street in the Bronx. The inspection was completed March 19, 2025.
Resident 39 remains identified only by number in the public record. Whether the test was eventually ordered again, and what it showed, is not documented in the inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for New Riverdale Rehab and Nursing from 2025-03-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 4, 2026 · Our methodology
New Riverdale Rehab and Nursing in Bronx, NY was cited for violations during a health inspection on March 19, 2025.
The resident, identified in inspection records only as Resident 39, was prescribed Depakote, a drug that requires periodic monitoring of levels in the blood.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.